Attachment and physical health

Question 1

What is the Human Systems of Homeostasis?

Answer 1

Act to balance internal and external factors that may affect a system and keep it functioning within certain parameters

Question 2

What are some regulatory systems that affect mental health?

Answer 2

Function:
Emotional Regulation

Systemic arousal/ energy conservation

Memory

Perception

Sleep /Wake cycle

Anatomical/Physiological Systems:
Limbic system

Autonomic system

Hippocampus/ Median Temporal lobe and Brain stem

Temporal Lobes and visual cortex

Pituitary /Endocrine

Question 3

wHAT IS THE limbic system concerned with?

Answer 3

Concerned with the modulation of Emotions and Instincts

Question 4

What does emotional dysregulation look like?

Answer 4

Extreme emotional outbursts
Uncontrolled temper
Self Harm
Difficulty maintaining relationships

Question 5

Which parts of the nervous are involved in hyperarousal and hypoarousal?

Answer 5

Hyperarousal – Sympathetic Nervous system
Hypoarousal - Parasympathetic Nervous system

Question 6

What are the causes of dysregulation?

Answer 6

Disrupted Attachment

Psychological Trauma (post Traumatic stress Disorder)

Temporary Effect of Trauma, Life Event or Stress

Question 7

How was the attachment theory developed?

Answer 7

Bowlby First described concept: Human and animals attached to caregiver who feeds them

Lorenz ‘52– goslings follow parent not for food

Harlow ’58 – monkeys bond to cuddly pole with food rather than wire food pole

Question 8

What is the theory behind attachment theory?

Answer 8

Attachment functions to protect infant from external dangers eg predators

Probable also emotional connection itself gives meaning/ has importance for our functioning

Social Animals

Essential for development of child

Affects individual through lifecycle

Question 9

What is the neurophysiology behind attachment theory?

Answer 9

Oxytocin

Area of brain mainly involved limbic system and Right Hemisphere

Autonomic System Regulation - Separation – increase pulse and decreased temperature. If prolonged or frequent can lead to changes in cortisol and so affects bodies response to stress eg increase in infection

Question 10

What is the window of tolerance

Answer 10

Window between 2 different bodily crises of hyper arousal - between flight/flight and freeze/dissociation

Question 11

What are the types of attachment styles

Answer 11

Secure
Anxious
Ambivalent
Avoidant

Question 12

What can affect attachment?

Answer 12

Iry caregiver emotionally unavailable eg depression

Drugs/ alcohol

Abuse/neglect
Anxious

Ambivalent

Avoidant

Question 13

What is the secure attachment style?

Answer 13

Able to internally self regulate the emotional neural systems and response to environment From about 5 years upwards

Develop reciprocal social bonds

Question 14

What is the anxious attachment style?

Answer 14

Maintaining attachment with a caregiver who is unpredictable
Clingy

Question 15

What is the ambivalent attachment style

Answer 15

Alternate clinging with excessive submissiveness to no trust

Role reversal – parent cared for by child

Dysregulation of fear and anger

Question 16

What is the avoidant attachment style

Answer 16

Child tries to minimise need for attachment to avoid rebuff

Remains in distant contact with the caregiver

When severe can ‘freeze’ when reunited with parent

Question 17

How can we treat certain attachment styles?

Answer 17

NB Brain remains ‘plastic’ into early 20’s

Treatment (Dialectic Behaviour Therapy) can change pattern

Treat co- morbidities eg depression, self harm, eating disorders

Question 18

Elana is in frequent trouble at school for aggressive outbursts. She is often in fights with her peers.
Elana’s mother had severe obsessive compulsive disorder Elana was often left crying and hungry.
Support was sought from Elana’s paternal grandparents and treatment accessed by her Mum
Elana presents with a three year history of drug misuse, self harm and suicide attempts.
She also presents with low mood and pseudohallucinations
In addition she presents with food restriction, vomiting and weight loss
Elana has been admitted twice with ongoing low mood after taking overdoses and with severe weight loss and refusal to eat.

Elana has now been discharged from hospital but her eating remains restricted . She has no suicidal ideas and her mood has improved.

She is taking Fluoxetine and engaged in Dialectic Behaviour therapy
What do you think the diagnosis may be? (there may be more than one)

Answer 18

Eating Disorder
Depression
Drug Misuse
Attachment Disorder/Emerging personality disorder/borderline personality disorder

Question 19

Elana is in frequent trouble at school for aggressive outbursts. She is often in fights with her peers.
Elana’s mother had severe obsessive compulsive disorder Elana was often left crying and hungry.
Support was sought from Elana’s paternal grandparents and treatment accessed by her Mum
Elana presents with a three year history of drug misuse, self harm and suicide attempts.
She also presents with low mood and pseudohallucinations
In addition she presents with food restriction, vomiting and weight loss
Elana has been admitted twice with ongoing low mood after taking overdoses and with severe weight loss and refusal to eat.

Elana has now been discharged from hospital but her eating remains restricted . She has no suicidal ideas and her mood has improved.

She is taking Fluoxetine and engaged in Dialectic Behaviour therapy
What subspecialty would you refer to in AMH?

Answer 19

) Eating Disorder Service, Access Team, Drug Misuse service, Personality Disorder service…
Co-Ordinator is essential

Question 20

Elana is in frequent trouble at school for aggressive outbursts. She is often in fights with her peers.
Elana’s mother had severe obsessive compulsive disorder Elana was often left crying and hungry.
Support was sought from Elana’s paternal grandparents and treatment accessed by her Mum
Elana presents with a three year history of drug misuse, self harm and suicide attempts.
She also presents with low mood and pseudohallucinations
In addition she presents with food restriction, vomiting and weight loss
Elana has been admitted twice with ongoing low mood after taking overdoses and with severe weight loss and refusal to eat.

Elana has now been discharged from hospital but her eating remains restricted . She has no suicidal ideas and her mood has improved.

She is taking Fluoxetine and engaged in Dialectic Behaviour therapy
What are your main areas of concern/risk for Elana?

Answer 20

Risk of relapse of eating disorder, drug misuse or mood disorder and self harm.
Care in labelling of Personality disorder when young

Question 21

Elana is in frequent trouble at school for aggressive outbursts. She is often in fights with her peers.
Elana’s mother had severe obsessive compulsive disorder Elana was often left crying and hungry.
Support was sought from Elana’s paternal grandparents and treatment accessed by her Mum
Elana presents with a three year history of drug misuse, self harm and suicide attempts.
She also presents with low mood and pseudohallucinations
In addition she presents with food restriction, vomiting and weight loss
Elana has been admitted twice with ongoing low mood after taking overdoses and with severe weight loss and refusal to eat.

Elana has now been discharged from hospital but her eating remains restricted . She has no suicidal ideas and her mood has improved.

She is taking Fluoxetine and engaged in Dialectic Behaviour therapy
How would you go about transitioning her?

Answer 21

Early referral important
Care co-ordinater
Transition meetings with Elana present

Question 22

What are some forms of SMI (Severe mental illness?)

Answer 22

Primary focus on Severe/Serious Mental Illness (SMI)
“Psychological problems that are often so debilitating that their ability to engage in functional and occupational activities is severely impaired”
Commonest disorders - schizophrenia and bipolar disorder, major depressive disorder
Cross-age prevalence ~0.7-0.9%

Drug and alcohol abuse
Dementia/Delirium (not focussed on during this talk, but delirium is a major contributor to morbidity/mortality)

Question 23

What are some physical co-morbidities in SMI?

Answer 23

Poor physical health is common

SMI patients are more likely (1.3x for females, 1.2x for males) to have one or more physical health conditions than all patients

Differences more pronounced in younger age groups
Highest health inequality in ages 15-34 for asthma, diabetes, HTN, obesity
SMI patients aged 15-34 are 5x more likely to have 3 or more health conditions

Inequalities persist for obesity, asthma, diabetes, COPD, CHD and stroke after controlling for deprivation, age and sex

Question 24

What is the impact of SMI on mortality?

Answer 24

Patients with SMI have a higher premature mortality than the general population

Average reduction in life is 15-20 years in SMI
Schizophrenia – 10-20 years
Bipolar Disorder – 9-20 years
Drug and alcohol use – 9-24 years
Recurrent depression – 7-11 years

Heavy smoking – 8-10 years
Death rate for those under 75years old is 3.7x higher than the general population
Estimated that 2/3 deaths are from preventable physical illnesses

Compared to general population, under 75s with SMI have death rates:
5 times higher for liver disease
4.7 times higher for respiratory disease
3.3 times higher for cardiovascular disease
2 times higher for cancer

Other causes of death include:
Suicide, substance abuse, accidents, dementia, infections

Question 25

Why does SMI have such a big impact on morbidity?

Answer 25

Effects of mental illness
Effects of prescribed medication
Effects of social circumstance
Effects of lifestyle
Effects of the healthcare system

Question 26

What are the effects of mental illness on morbidity?

Answer 26

Direct effect of symptoms of mental disorder on physical healthcare

Schizophrenia/psychosis
Delusional beliefs about physical health
Delusions of causes of physical disorders
Paranoia/persecutory beliefs about healthcare staff
Delusional beliefs around treatments/medications
Chronic thought disorder leads to challenging engagement
Negative symptoms
- Amotivation
- Social withdrawal
- Cognitive impairment
Major Depressive Disorder
Amotivation
Apathy
Beck’s Cognitive Triad (negative thoughts about the world, self and future)
Worthlessness/hopelessness/guilt

Anxiety
Significant social anxiety – not leaving home/secure address

Dementia
Cognitive impairments
lack of concordance with medication
Missed appointments

Question 27

What are the effects of prescribed medication on morbidity?

Answer 27

Many psychotropic medications have impacts on physical illness

Metabolic Syndrome
Type 2 Diabetes Mellitus
CVD
Bone Mineral Density Loss
Renal Disease
Thyroid Disease
Other miscellaneous disorders

Question 28

What is metabolic syndrome?

Answer 28

Clustering of abnormalities
Central obesity
Hypertension
Dyslipidaemia
Glucose Intolerance/Insulin Resistance
Hypertension

5-6 fold increase in risk of developing T2DM
3-6 fold increase in risk of mortality due to CVD

May be an aetiological factor in some cancers (particularly colon cancer

Question 29

Prevalence of metabolic syndrome

Answer 29

Prevalence in schizophrenia varies in studies, depending on multiple factors (MetS criteria, gender, ethnicity, country, age group, antipsychotic treatment)

Prevalence ~19.4 - 68%!

Higher prevalence in schizophrenia compared to general population

Bipolar disorder prevalence ~ 22-30%

Caused/exacerbated by various antipsychotics (particularly atypicals)

Question 30

What can cause obesity/ weight gain in SMI?

Answer 30

Antipsychotics
Clozapine/Olanzapine
Quetiapine/Risperidone (intermediate risk)

Antidepressants
Mirtazapine, paroxetine

Mood Stabilisers
Lithium, Valproate
Linked to metabolic syndrome, general poor health
Other meds of course linked, but these are common ones

Question 31

T2DM on SMI

Answer 31

Atypical antipsychotics higher risk than typicals
Atypical D2 receptor antagonism may have direct effect on development of glucose intolerance (initially via blunted insulin secretory response)

Olanzapine/Clozapine highest risk
Risperidone intermediate risk

Antidepressants may increase risk
Likely due to side-effects of increased appetite/sedation/weight gain

Question 32

Bone mineral density loss in SMI

Answer 32

Many antipsychotics lead to raised prolactin levels
It is suggested that hyperprolactinaemia leads to BMD loss
although studies are contradictory

May be more related to lifestyle issues
Smoking, reduced physical activity, reduced vitamin D production, alcohol abuse

High risk factor for fractures
Hip fractures are related to high morbidity/mortality
Other fractures may precipitate pain/further loss of mobility and independence

Question 33

What are some msicellaneous drug-related disorders?

Answer 33

Lithium
Clinical hypothyroidism (up to 47% of patients!)
Renal failure

Clozapine
Agranulocytosis
Myocarditis
Chronic severe constipation (spontaneous bowel perforation)

Question 34

What are the effects of social circumstance?

Answer 34

Health generally worse in deprived communities

Life expectancy lower in deprived communities

Prevalence/Incidence of psychotic disorders 2.5-3.1x higher in most deprived areas compared to least deprived areas

Social drift theory
Symptoms of SMI/deterioration of cognitive functioning leads to difficulties with functioning and maintenance of living standards
Individuals with SMI “drift” into progressively lower socioeconomic bands and/or areas with increased deprivation
Social isolation leads to reduced contact with healthcare professionals

Reluctance to attend check-ups/health visits
Cognitive difficulties
Poor interactions with healthcare professionals
Detentions under MHA
Poor interactions in general health wards/A&E can be related to stigma

Question 35

Effects of lifestyle on co-morbidity in SMI

Answer 35

Smoking!
Smoking reducing in general population, but stable in SMI
Some studies suggest ~60% of adults with schizophrenia are regular tobacco smokers

Poor diet
Lack of exercise

Amotivation
Social isolation
Cognitive dysfunction
Stigma
Drug and alcohol use
~41% dual diagnosis

Direct physical illness
Liver disease
Brain damage (e.g. Wernicke/Korsakoff disease)
Accidental overdose
Related illness
VTE
HIV
Hepatitis/BBV

Question 36

What are the effects of the healthcare system on morbidity with SMI?

Answer 36

Division of healthcare system and training into silos
Psychiatrists focus on mental over physical health
De-skilling psychiatrists in physical medicine
Poor communication due to separation of physical/mental health wards
Completely different sites – RHH/NGH vs MCC/Longley

Who is responsible for monitoring of physical health?
GPs?
Psychiatrists (given number of physical risks of psychotropic meds)?
Lower level of healthcare intervention in SMI

Lower rates of cardiac stenting or bypass grafting in schizophrenia with CVD
People with psychosis are less likely to receive warfarin following CVA
SMI patients less likely to receive routine cancer screening
Standard of diabetes care is likely to be lower in SMI

Related to patient-level effects (as described before)

But also… stigma

Question 37

What is diagnostic overshadowing?

Answer 37

Initially in LD patients

Assumption that behaviour is due to their learning disability rather without exploring biological determinants

Can be extended to SMI/Dementia/Delirium

Once a patient has a diagnosis, all new symptoms are assumed to be due to that
Woman on AMU with a history of depression, presented with confusion, fever, cough.
Medical team referred to psych as she was refusing blood tests and thought confusion must be mental illness, without assessing for delirium/sepsis

Question 38

How can we target health behaviours and MetS (Metabolic syndrome)?

Answer 38

Targeting health behaviours
Smoking
Poor diet
Lack of exercise

Targeting signs of Metabolic Syndrome (MetS)
Obesity
BP
Glucose Regulation
Blood Lipids

Question 39

Further interventions for SMI

Answer 39

Actively and effectively treat psychiatric illness
Appropriate treatment at appropriate dose
Proactive treatment of symptoms with aim for functional recovery
Active treatment of comorbid substance misuse

STOMP/STAMP
Stopping overmedication of young people with LD/autism or both
Initially an LD/Paediatric initiative, but applicable to adult/OA psychiatry
Does this patient really need this medication at this dose?

Patient education about risk factors and management of diseases
Diabetes courses
Healthy heart information

Awareness training (this session) and reduction of stigma in healthcare professions

?Review of healthcare systems and how these are organised
Reduction in silo-ing and integrated physical/mental healthcare